Few termination of life-support cases present irreconcilable ethical problems.
[Weir RF, Gostin L. Decisions to abate life-sustaining treatment for
nonautonomous patients: ethical standards and legal liability for physicians
after Cruzan. JAMA. 1990;264:1846–1853.] Most of the patients involved are
going to die relatively quickly, irrespective of treatment. All but a few of the
rest will be condemned to a persistent vegetative state, which they have
previously rejected as unacceptable. Family members may have personal
psychological reasons to resist the termination of life support. These are not
compelling, however, because of the patient’s inability to contribute either
personally or financially to family life. Unlike refusal of curative therapy, there
is no compelling ethical basis for a physician or hospital to resist the
termination of essentially futile treatment. Once treatment becomes both
ineffective and unacceptable to the patient, society’s interest is to preserve its
resources for other patients. [Callahan D. Setting limits: Medical goals in an
aging society. Washington, DC: Georgetown University Press; 1995.]
This leaves a residuum of hard cases, cases such as that of Hector Rodas.
Rodas suffered an accidental brain injury that left him mentally competent but
otherwise totally dependent on life-support technology. He could neither speak
nor swallow. He could respond to yes or no questions by nodding his head,
which allowed him to spell out messages with the help of a therapist pointing
to letters on a board. By this means, Rodas requested that he no longer be fed
or hydrated. The hospital required Rodas, through his lawyer, to seek a court
order discontinuing life support. The court ultimately ruled that Rodas could
refuse nutrition and hydration while remaining in the hospital. [Miller DH. Right
to die damage actions. Denver Law Rev. 1988; 65:184.]
The physicians and the hospital in this case were reluctant to terminate
treatment without a court order, but it is difficult to imagine a court refusing
Rodas’s request to be allowed to die. According to Mishkin, [Mishkin DB. You
don’t need a judge to terminate treatment.
J Intensive Care Med.
1990;5:5201–5204.] allowing Rodas to die without a court order is certainly
legally proper. Considering the prolongation of Rodas’s suffering caused by the
court action and his extremely limited prognosis, it may be more than merely
legal. In cases such as this one, where none of the stakeholders other than the
patient has a compelling interest, the delays and suffering inherent in judicial
process make such a course of action ethically questionable.